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INTRODUCTION

Mrs. S, a 65-year-old woman with type 2 diabetes, high blood pressure, chronic obstructive lung disease (COPD), and ­lumbar back pain, comes to her primary care clinic for ­routine follow-up. Mrs. S takes metformin, glipizide, benazepril, Advair®, Spiriva®, albuterol, and ibuprofen. She lives alone as her husband passed away. She manages her own medications, shopping, cooking, and cleaning. She has a daughter who visits her weekly. During her appointment, she reports difficulty picking up all of her medications due to “insurance issues.” She has not been regularly checking her blood sugar at home and reports “cheating” a lot lately, especially when baking for her grandchildren. She complains of worsening back pain, limiting her ability to attend her weekly dance class. She missed her scheduled mammogram because she got lost looking for the mammography center at an offsite location. Her recent hemoglobin A1c has increased from 7.5% to 9.0% and her diabetic foot exam shows decreased sensation. She leaves her visit with an appointment with the ­medical social worker to discuss medication insurance coverage, a handout on lower back stretches to practice at home, a referral to prosthetics to pick up diabetic shoes, instructions on daily foot care, a blood sugar tracking form with instructions to monitor her blood sugar three times a day to help decide if she should be started on insulin, a map of the hospital’s offsite facilities to help her find the mammography center, and a ­computer-generated summary of her primary care visit. She is given the phone number to reschedule her mammogram, and follow-up appointments to see the diabetes nurse in 6 weeks and her primary care provider in 3 months.

In order to maintain good health, patients are expected to communicate concerns clearly with providers, understand written and verbal instructions, partner with providers to make decisions about screening and choose treatment options, engage in self-management activities at home and in their communities, and negotiate a complicated and often fragmented health-care system. These are complex tasks requiring a high-level of health ­literacy. The various definitions of health literacy (Box 15-1) reflect a dynamic interplay between the literacy demands and attributes of the health-care environment and the personal skills of patients.